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RN Medical Reviewer (4764)

Claims Review Mgmt | Columbia, SC | Contract

Job Description

RN Medical Reviewer
Work Location: Columbia, SC

Job Summary/Description

The RN Medical Reviewer will be responsible for performing medical reviews using clinical/medical information provided by physicians/providers and established criteria/protocol sets or clinical guidelines. Decisions will be documented using indicated protocol sets or clinical guidelines. The RN will provide support and review of medical claims and utilization practices. If you meet the qualifications, please apply and a Recruiter will reach out to you and answer any questions you may have.

Job Duties/Responsibilities/Functions(including but not limited to)

• Performs medical claim reviews for one or more of the following: claims for medically complex services, services that require preauthorization/predetermination, requests for appeal or reconsideration, referrals for potential fraud and/or abuse, and correct coding for claims/operations.

• Makes reasonable charge payment determinations based on clinical/medical information and established criteria/protocol sets or clinical guidelines.

• Determines medical necessity and appropriateness and/or reasonableness and necessity for coverage and reimbursement.

• Documents medical rationale to justify payment or denial of services and/or supplies.

• Educates internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines.

• Participates in quality control activities in support of the corporate and team-based objectives.

• Provides guidance, direction, and input as needed to LPN team members. Provides education to non-medical staff through discussions, team meetings, classroom participation and feedback.

• Assists with special projects and specialty duties/responsibilities as assigned by Management.

Minimum Qualifications

• Associate degree in Nursing

• 2+ years of clinical experience

• Active and unrestricted RN license in the state of SC

Key Words: Nurse Case Manager, Utilization Review, Registered Nurse, CCM

About InGenesis

InGenesis is dedicated to placing people in positions that preserve life, improve lives and inspire others. This does not happen without passionate people, skilled colleagues who are motivated to create innovative solutions and deliver superior service to our clients. Founded in 1998, InGenesis manages thousands of employees, including pioneering healthcare, science, technology and pharma professionals. The workforce solutions company includes almost half of the Fortune 500 in its nearly 300 clients. It is recognized as one of the largest healthcare staffing firms, and InGenesis is the largest minority/women owned healthcare staffing firm in North America.

EEOC Statement

We support a diverse workforce and is an Equal Opportunity Employer who does not discriminate against employees and applicants for employment on the basis of race, gender, color, religion, national origin, age, sexual orientation, gender identity, genetic information, disability, veteran status, or other classification protected by law.